Provider Demographics
NPI:1881645190
Name:SHOPKO STORES OPERATING CO LLC
Entity Type:Organization
Organization Name:SHOPKO STORES OPERATING CO LLC
Other - Org Name:SHOPKO OPTICAL 098
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VICE PRESIDENT HEALTH SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:BETTIGA
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:920-429-4297
Mailing Address - Street 1:2815 CHAD DR
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97408-7335
Mailing Address - Country:US
Mailing Address - Phone:541-686-0838
Mailing Address - Fax:
Practice Address - Street 1:2815 CHAD DR
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97408-7335
Practice Address - Country:US
Practice Address - Phone:541-686-0838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
OROR04942OtherNORIDIAN SUBMITTER ID
014098OtherVIP
OR004379Medicaid
42581OtherDAVIS VISION
CP2230-35OtherEYEMED
CP2230-35OtherEYEMED
DF1182Medicare PIN
OROR04942OtherNORIDIAN SUBMITTER ID
014098OtherVIP
OR5695760100Medicare NSC